Current through Register Vol. 24-18, September 15, 2024
(1) Any enrolled
contractor or provider of medical services has a right to an administrative
appeal when the contractor or provider disagrees with the medicaid agency
reimbursement rate. The exception to this is nursing facilities governed by WAC
388-96-904.
(2) The first level of appeal. A contractor
or provider who wants to contest a reimbursement rate must file a written
appeal with the agency.
(a) The appeal must
include the following:
(i) A statement of the
specific issue being appealed;
(ii)
Supporting documentation; and
(iii)
A request for the agency to recalculate the rate.
(b) When a contractor or provider appeals a
portion of a rate, the agency may review all components of the reimbursement
rate.
(c) To complete a review of
the appeal, the agency may do one or both of the following:
(i) Request additional information; and
(ii) Conduct an audit of the
documentation provided.
(d) The agency issues a decision or requests
additional information within sixty calendar days of receiving the rate appeal
request.
(i) When the agency requests
additional information, the contractor or provider has forty-five calendar days
from the date of the agency's request to submit the additional
information.
(ii) The agency issues
a decision within thirty calendar days of receipt of the completed
information.
(e) The
agency may adjust rates retroactively to the effective date of a new rate or a
rate change. In order for a rate increase to be retroactive, the contractor or
provider must file the appeal within sixty calendar days of the date of the
rate notification letter from the agency. The agency does not consider any
appeal filed after the sixty-day period to be eligible for retroactive
adjustment.
(f) The agency may
grant a time extension for the appeal period if the contractor or provider
makes such a request within the sixty-day period described in (e) of this
subsection.
(g) Any rate increase
resulting from an appeal filed within the sixty-day period described in
subsection (2)(e) of this section is effective retroactively to the rate
effective date in the notification letter.
(h) Any rate increase resulting from an
appeal filed after the sixty-day period described in subsection (2)(e) of this
section is effective on the date the rate appeal is received by the
agency.
(i) Any rate decrease
resulting from an appeal is effective on the date specified in the appeal
decision letter.
(j) Any rate
change that the agency grants that is the result of fraudulent practices on the
part of the con-tractor or provider as described under
RCW
74.09.210 is exempt from the appeal
provisions in this chapter.
(3) The second level of appeal. When the
contractor or provider disagrees with a rate review decision, it may file a
request for a dispute conference with the agency. For this section "dispute
conference" means an informal administrative hearing to resolve contractor or
provider disagreements with an agency action as described under subsection (1)
of this section and not agreed upon at the first level of appeal. The dispute
conference is not governed by the Administrative Procedure Act, chapter 34.05
RCW.
(a) If a contractor or provider files a
request for a dispute conference, it must submit the request to the agency
within thirty calendar days after the contractor or provider receives the rate
review decision. The agency does not consider dispute conference requests
submitted after the thirty-day period for the first level decision.
(b) The agency conducts the dispute
conference within ninety calendar days of receiving the request.
(c) An agency-appointed conference
chairperson issues the final decision within thirty calendar days of the
conference. Extensions of time for extenuating circumstances may be granted if
all parties agree.
(d) Any rate
increase or decrease resulting from a dispute conference decision is effective
on the date specified in the dispute conference decision.
(e) The dispute conference is the final level
of administrative appeal within the agency and precedes judicial
action.
(4) The agency
considers that a contractor or provider who fails to attempt to resolve
disputed rates as provided in this section has abandoned the
dispute.
11-14-075, recodified as §182-502-0220, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090. 10-19-057, § 388-502-0220,
filed 9/14/10, effective 10/15/10. Statutory Authority:
RCW
74.08.090 and
74.09.730. 99-16-070, §
388-502-0220, filed 8/2/99, effective 9/2/99. Statutory Authority:
RCW
74.08.090. 94-10-065 (Order 3732), §
388-502-0220, filed 5/3/94, effective 6/3/94. Formerly WAC
388-81-043.
